# NTSB ERA10LA014: Beech E35, N3515B, Mount Morris, NY, October 10, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 10, 2009, 15:45 local (19:45 UTC) - Place: Mount Morris, NY - Coordinates: 42.674999, -77.873886 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.6750&lon=-77.8739&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 19, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 74885 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74885/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74885 - Page: https://openairdocs.org/ntsb/ERA10LA014 ## Probable cause The pilot’s improper decision to take off from unsuitable terrain with a quartering tailwind. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech E35, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151512), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Effect on operation; cases with it: [Beech E35, 1 case](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=1151512), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Decision related to condition; cases with it: [Beech E35, 1 case](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=1151512), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff-rejected takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Beech E35, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=1151512), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot attempted a quartering tailwind takeoff from a 1,200-foot turf runway to troubleshoot why the entry door would pop open on takeoff. Although the airplane initially became airborne, it was either unable to maintain flight, or the pilot elected to land it in a hayfield beyond the end of the runway. After inspecting the airplane, the pilot taxied it to another spot on the rough-surfaced hayfield, and attempted another quartering tailwind takeoff. Again, after briefly becoming airborne, the airplane landed, but then went through a hedgerow and crossed a drainage ditch. Other than the entry door, the pilot reported no mechanical anomalies with the airplane. The pilot did not have a logbook, and had not had a biennial flight review “in a few years,” but continued to fly on a regular basis. The pilot also did not hold a current medical certificate, and was taking prescribed medications on a daily basis that typically would not have been approved by the Federal Aviation Administration. ## Factual narrative On October 10, 2009, about 1545 eastern daylight time, a Beech E35, N3515B, was substantially damaged during a takeoff attempt from a hayfield in Mount Morris, New York. The certificated private pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to initial reports from the pilot, the airplane had a history of the entry door popping open during takeoff and he was trying to troubleshoot the problem. The pilot attempted to take off from runway 4 at J.C. Palermo Airpark, Mount Morris, New York, a 1,200-foot runway at an elevation of 962 feet. However, when the door popped open, he became startled and aborted the takeoff, but too late to stay on the runway. The pilot also acknowledged that he attempted to take off downwind. In a later telephone interview, the pilot confirmed that he attempted the downwind takeoff, and while doing so, the airplane’s door opened. He also stated that the airplane never left the ground, and he therefore was conducting a high speed taxi. However, as noted in a state police report, three witnesses reported that the airplane did take off, with one stating that it reached an altitude of about 25 feet above the runway, before it landed in a hayfield beyond the end of the runway. The pilot never mentioned a second takeoff attempt. Two of the three witnesses stated that after landing in the hayfield beyond the runway, the pilot got out, inspected the airplane, and stated, “I think everything’s okay.” He later taxied the airplane across the hayfield and made a second takeoff attempt from there rather than the runway. Both witnesses indicated that the airplane briefly became airborne again before settling back down onto the field. The state police report noted ground scars about 600 feet in length which led through a hedgerow and across the drainage ditch to the airplane, which sustained fuselage and left wing damage. According to a Federal Aviation Administration (FAA) inspector, the ground scars headed northeast toward the airplane. In addition, the hayfield had a rough, uneven surface to it. The pilot stated that, other than the access door, there were no mechanical anomalies with the airplane. The pilot’s latest FAA medical certificate was “pending” as of May 23, 2000. According to a list provided to the FAA inspector, the pilot was utilizing prescribed medications on a daily basis, including alprazolam, carbamazepine, fluoxetine, and buspirone. The pilot also stated that he had lost his logbook and had not had a biennial flight review “in a few years,” but continued to fly on a regular basis. Weather, recorded at the airport in Dansville, New York, about 12 nautical miles (nm) to the southeast, at 1554, included winds from 280 degrees true at 8 knots. Weather, recorded at the airport in Rochester, New York, about 25 nm to the northeast, at 1554,included winds from 280 degrees true at 6 knots. ## Aircraft - Registration: [N3515B](https://openairdocs.org/deregistered/N3515B-2012-04-17), registration cancelled 2012-04-17, S/N D-3732, built 1954 (OpenAirDocs) - Reported make and model: BEECH E35 - Registry model: [Beech E35](https://openairdocs.org/model/beech-e35) (registry code 1151512) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-3732 - Airframe hours: 3915 - Engines: CONT MOTOR E185 SERIES 205 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 13, 2009 - Departed: NONE, Mount Morris, NY - Destination: NONE, Mount Morris, NY - Airport: NONE, JC Palermo Airpark, runway 04, 1,200 × 50 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: serious; private; airplane ratings: single-engine land; seat: left; flight hours: 2,400 total, 1,800 in this make and model, 2,200 as pilot in command, 50 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 8 knots - Visibility: 10 statute miles - Temperature: 57 °F, dew point 37 °F - Altimeter: 30.05 inHg - Observed at: DSV, 12 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20091010050789A](https://openairdocs.org/incident/20091010050789A), Oct 10, 2009: Beech E35, Mount Morris, NY, Substantial damage. First time pilot tried to take off down wind from runway 04 on a 1200 feet grass strip. Second time pilot again tried to takeoff from a hay field down wind and… ## Other investigations on N3515B (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB UNK65X1250](https://openairdocs.org/ntsb/UNK65X1250), Jan 7, 1965: Beechraft E35 (N3515B), Oakland, CA, substantial damage ## Docket (5 files) The files NTSB released with the investigation on February 12, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74885. 752 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324235&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - New York State Police Report (item 2, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322699&FileExtension=.PDF&FileName=New%20York%20State%20Police%20Report-Redacted.PDF - Memorandum for Record (#1) (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321300&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20(%231)-Redacted.PDF - Memorandum for Record (#2) (item 4, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321305&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20(%232)-Redacted.PDF - Pilot Submissions (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322023&FileExtension=.PDF&FileName=Pilot%20Submissions-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.